Homograft Repair of Aortic Root Abscess in Prosthetic Valve Endocarditis

The authors show the case video of homograft aortic root replacement for prosthetic valve endocarditis.

The case is a 59-year-old man on chronic oral steroid who underwent biological aortic valve replacement six months ago. He came back with heart failure symptoms and an echocardiogram showed severe aortic regurgitation with root abscess. With this finding, he was taken to the OR for homograft aortic root replacement.

Standard resternotomy and cannulation was performed and the patient was put on bypass and cooled to 32 degree Celsius. The aorta was opened and the root was retracted with stay sutures. The aortic valve was inspected and the surrounding tissues were dissected. Most of the sutures and pledgets came out with the valve by just gentle pulling and blunt dissection, and the aortic valve was removed. Abnormal tissues were removed from the aortomitral curtain and around the root under the left main and the membranous septum. The right coronary ostia was mobilized from the surrounding root. The left coronary ostia was next mobilized with sharp dissection and cautery. A 27 mm Edwards Magna Ease sizer fit easily in the root and the authors selected a 27 mm homograft. Then they finished completing the debridement of the root. A strip of bovine pericardium was prepared for the proximal anastomosis.

The proximal sutures were placed in the root using 4-0 prolene, securing good bites in the friable tissue. A total of 33 interrupted sutures were placed around the annulus, incorporating a strip of bovine pericardium for additional support. The homograft was trimmed, leaving a generous cuff of muscle as well as the donor mitral leaflet. Each commissure of the homograft was marked. Starting at the commissure between the right and left coronary sinus, the sutures were passed in the order of left coronary sinus, noncoronary sinus, and right coronary sinus. Once all sutures were passed, the homograft was slid down and sutures were tied down. The homograft was implanted in original anatomical position. Saline test confirmed homograft valve competency. The distal end of the homograft was trimmed, and the location for the right coronary button was marked. The left coronary ostium of the homograft was matching to the patient position, and the stump was opened and enlarged.

The left coronary button was reimplanted using 5-0 prolene in a continuous fashion. The location of the right coronary was opened, and the right coronary button was reimplanted in a similar fashion. A dose of bioglue was applied to the root and coronary buttons. A second strip of bovine pericardium was prepared for the distal aortic anastomosis. This anastomosis was completed using a running 4-0 prolene suture.

The patient came off bypass with minimal inotropic support, and the echocardiogram confirmed good biventricular function and no aortic regurgitation. The postoperative course was uneventful, and the patient went home on postoperative day six.

References

1. Musci M, Weng Y, Hubler M, Amiri A, Pasic M, Kosky S, et al. Homograft aortic root replacement in native or prosthetic active infective endocarditis: twenty-year single-center experience. J Thorac Cardiovasc Surg. 2010;139(3):665-673.
2. Leontyev S, Davierwala PM, Krogh G, Feder S, Oberbach A, Bakhtiary F, et al. Early and late outcomes of complex aortic root surgery in patients with aortic root abscesses. Eur J Cardiothorac Surg. 2016;49(2):447-54; discussion 54-55.
3. Solari S, Mastrobuoni S, De Kerchove L, Navarra E, Astarci P, Noirhomme P, et al. Over 20 years experience with aortic homograft in aortic valve replacement during acute infective endocarditis. Eur J Cardiothorac Surg. 2016;50(6):1158-1164.

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